ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING RATIONALE EVALUATION

PROBLEM INTERVENTIONS
Subjective: For optimal cell functioning STO: Within 4 hour of Dx: Dx: STO:
“maululawak garod the kidney excrete effective nursing  Assessed the general  To obtain baseline data. Goal Met
sagpaminsan ken kasla potentially harmful interventions, the patient condition and After 4 hour of effective
agpipikel ti ramay ko ken di nitrogenous product-Urea, will be able to: monitored vital signs. nursing intervention the
ak unay makaisbo” Creatinine, Uric Acid but  Assessed patient  Stress or depression client understand the risk
because of the loss of  Verbalized emotional/psychologica may be increasing the factors or condition when to
Objective: kidney excretory functions understanding of l factors affecting the effect of an illness or contact health care provider
 Increase in BUN, there is impaired excretion risk factors or current situation depression might be the and he demonstrated
Creatinine, Uric of nitrogenous waste condition, therapy result of being forced participation on
Acid Level product causing in increase regimen, side effect into inactivity. recommended treatment
 Hypertension in Laboratory result of of medications, and  Noted mentation status  Increase BUN and program.
 Pulmonary BUN, Creatinine, Uric Acid when to contact and review lab result Creatinine levels may
Congestion Level health provider. such as BUN and alter mentation LTO:
 Hematuria creatinine levels. Goal Met
 Oliguria  Demonstrate  Noted characteristics of  To assess for hematuria After 3 days of effective
participation in his urine: measure urine and proteinuria and nursing intervention the
 Anuria
recommended specific gravity renal. patient demonstrated
treatment program. behavior changes to prevent
Nursing Diagnosis: complication
Altered Renal Tissue Tx: Tx:
Perfusion related to  Established rapport  To get the cooperation
Glomerular Malfunction as LTO: Within 3 days of of the patient.
evidenced by Increase in effective nursing  Calories to meet body’s
BUN, Creatinine and Uric interventions, the patient  Provided diet restriction need while restriction of
Acid level will be able to: as indicated, while protein helps limit
providing adequate BUN.
 Demonstrate calories.
behavior/lifestyle  Provided physiological  Honestly can be
changes to prevent support. Maintained reassuring when so
complications calm attitude but admit much activity or worries
concerns if questioned are apparent to the
by the client/SO. client or SO.
 Administered
medication as ordered.  For faster recovery. It is
used to treat the client’s
disease condition.
 Promoted overall health  To promote wellness.
measure.
Edx:
Edx:  To provide opportunity
 Educated client/SO in for timely evaluation
reportable symptoms, and intervention.
including any changes
in pain level, difficulty
walking nonhealing
wounds.
 Emphasized need for  To evaluate disease
regular medical and progression and
laboratory follow-up. response to therapies.
 Encouraged discussion  To decrease anxiety
of feelings regarding about condition and
prognosis or long-term correct his wrong ideas
effect of discussion. about condition.
 Encouraged to maintain  To enhance sense of
positive attitude; well-being.
suggest use of
relaxation technique
such as guided imagery
as appropriate.
 Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation
Problem
Objective: Alterations in the immune STO: Dx: STO:
 Hyperthermia system that occur with After 1 hour of nursing  Assessed causative contributing  Personal habits or living situations Goal Met
 Low Bicarbonate chronic kidney dysfunction intervention, the patient will: factors. can increase susceptibility to Within 1 hour of effective
 Elevated WBC are associated with increased  Verbalize understanding infection. nursing interventions, the
susceptibility to infections of individual causative or patient is afebrile and was
 Increase ammonia
and poor vaccine response. risk factors.  These represent a break in the able to verbalized
and Urea Metabolic acidosis reflects understanding causative
 Identify interventions to  Assessed for the presence, body’s normal first line of defense.
an excess of acid (hydrogen) prevent or reduce risk of existence of, and history of risk factors and identify to
Nursing Diagnosis: and a deficit of base infection. prevent infection.
Risk for infection related factors such as sufficient
(bicarbonate) resulting from  Be afebrile
to metabolic acidosis knowledge to avoid exposure to
acid overproduction, loss of
intestinal bicarbonate, pathogens which related to tissue LTO:
LTO:
inadequate conservation of trauma. Partially Met
After 8 hours of effective
bicarbonate, and excretion of nursing intervention, the After 8 hours of effective
acid, or anaerobic patient will:  Assessed la results for infection  To prevent and treat an infection. nursing intervention, the
metabolism.  Demonstrate (elevated WBC and positive patient demonstrate
techniques, lifestyle blood cultures). lifestyle changes to
promote safe environment.
change to promote
safe environment  Assessed temperature,  Provides information about the
 be free from signs and respiratory and urinary system presence of infection caused by
symptoms related to changes as the disease progressive chronic disease and its
infection. progresses. deteriorating effect on all systems.
Tx:
 Reduce existing risk factors.
Tx:
 Provided clean, well ventilated
environment.
 Aseptic technique decrease
 Maintained aseptic technique for changes of transmission or
dressing changes and wound
 care. spreading pathogens to the patient.
 At high risk for nosocomial or
 Performed daily mouth care. HAIs.
Include use of antiseptic
mouthwash for individuals in
acute or long-term care settings.

 Administered antibiotic therapy  Prevents or treat an infection.

Edx: Edx:
 Emphasized necessity of taking  Antibiotic works best when a
antibiotics as directed if infection constant blood level is maintained
occurs. Instruct to take the well which is done when medication
course of antibiotics even if are taken as prescribed. Not
symptoms improve or unnoticed. completing the regimen can lead to
drug resistance in the pathogens
and reactivation of symptoms.

 Recommended to increase intake  It increases the immune system in

 Taught the patient and/or